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CPT Code 30465 with 20912 – Repair of Nasal Valve Stenosis with Septal Cartilage Grafting - AGOSTINO Equipment: Supplies: ` Headlight; Suction; Nasal Set including: Nasal Speculae 25 mm, 45 mm, and 70 mm; Adson –Brown Forceps; Adson – single tooth pick-ups; two mosquito hemostat forceps; Boies butter knife; Swivel knife; Freer elevator; Cottle elevator; Cottle knife; Woodson elevator; 15 blade handle; Ferris-Smith Forceps; Takahashi Forceps; #7, #10 Frazier Suction; Bayonet Forceps; Gorney Turbinate Scissors, Jansen-Middleton Forceps; Hammer; Chisel; and, Separate Mayo-Stand 1. Sutures – 5.0 Monocryl 493G; 4.0 Monocryl Y315 dyed purple; 4.0 Vicryl on RB-1 – J214; 4.0 Black Nylon - cutter 2. Drapes – 4 towels; Standard Split Sheet or Body drape; Drape of Head 3. Prep: Ivory Soap 4. Fluids: 1 Liter Saline for Irrigation and for cartilage support 1 Liter of Water for Cleaning Instruments 5. Medications: 1% Xylocaine and 1:100,000 epinephrine solution; Topical oxymetazoline 5. Gloves: 8 ½ Latex-Free and Powder-Free (2Pairs) 6. Dressing: ½”Steri – Strips; mastisol; Reuter bi-valve splints (0.25mm) 7. Misc. - Yankauer Suction; Orogastric Tube, Ray-tec; ½” x 3” cottonoids; 10 cc control syringe and 27 Gauge Needle; small basins ( 3 round and one rectangular) Mayo Set-up: #1 Initial Mayo is to the right of the patient and has local anesthetic; topical afrin; and bayonet forceps and small 25 mm nasal speculum for nasal decongestion prior to prep. #2 Mayo Stand: L to R – and closest to pt.: Nasal Speculae 25 mm, 45 mm, and 70 mm; Adson –Brown Forceps; Adson – single tooth pick-ups; two mosquito hemostat forceps; Boies butter knife; Swivel knife; Freer elevator; Cottle elevator; Cottle knife; Woodson elevator; 15 blade handle; Second Row, away from patient: Ferris-Smith Forceps; Takahashi Forceps; #7, #10 Frazier Suction;Bayonet Forceps Sequencing 1. The patient is taken to the operating room and placed under general endotracheal anesthesia with the tube taped in the midline of the mandible. The patient is rotated 90 degrees so that the left arm of the patient usually goes toward the anesthesiologist. 2. Four of the 1/2” x 3” cottonoids are soaked in topical Afrin and two are placed in each nostril. 3. The oral cavity is injected at the greater palatine foramina with 1% Xylocaine with 1:100,000 epinephrine solution using a 10 mL control syringe and a 27-gauge needle. 4. The nose will be injected with attention to the septum and front part of the nose as well as the collumela, the upper lateral cartilages and as well as the lateral side walls in both sides of the nasal septum. 5. The face will then be cleansed with the preparatory solution of Ivory soap on 4” x 4” gauze. 6. The head will be draped with 2 towels underneath the head and a towel clip to hold the towels out of the way as well as placing the towel across the oral cavity. The split sheet across the body is used to cover up the area around your head. 7. An hemi-transfixion incision is made on the left side nose at the caudal end of the septum with a 15-blade knife while retracting the collumela with a 25-mm nasal speculum for exposure. 8. The Cottle knife is used to better define the planes in the right and left side of the mucoperichondrium of the cartilage. 9. To elevate the right-sided submucoperichondrial plane up to the space just behind the upper lateral cartilage, a Woodson Elevator and a 45-mm long Cottle speculum are used. 10. The inferior one-half of the attachmment of the upper lateral cartilage to the septum on the right side is divided. 11. The left side of the nose is exposed with the 45 mm speculum and the submucoperichondrium of the left side of the septum is elevated extending to the bony cartilaginous junction. 12. The Freer elevator is used to expose the inferior strip of septal cartilage on the left side of the nose. 13. The submucoperiosteal plane over the vomer and perpendicular plate of the ethmoid is elevated with a Cottle elevator posteriorily to the sphenoid sinus region. 14. The Anterior portion of the septal cartilage is cut vertically, at least 15 mm posteriorly to the caudal end of the septum, with a Cottle knife, leaving an anterior L-shaped cartilaginous strut. 15. A separate transverse cut is made posteriorly with the Cottle knife over the superior aspect of the inferior cartilage strip. 16. The Swivel knife is used to make a posterior and inferior cut along the bony cartilaginous junction after using the Cottle elevator to elevate the right sided sub- mucoperichondrial flap. 17. The superior portion of the septal cartilage is removed from the mid portion of the nose using Ferris-Smith forceps and this cartilage is set aside in a bowl of saline in the middle of the Mayo stand. 18. The inferior strip of cartilage is then elevated off of the vomer with a Freer elevator and the cartilage grasped with the Ferris-Smith forceps and placed in the saline. 19. We then elevate a right sided sub-mucoperiosteal flap on the right side of the bone. 20. The bone that is deviated off of the mid-line is then cut with the Gorney Turbinate scissors and Jansen-Middleton forceps while retracting the septal mucosal flaps with a 70 mm long speculum. The bone is removed with Takahashi forceps and set aside in saline. 21. The cartilage that was harvested from the nose is then fashioned into the spreader grafts. The spreader graft for the right side is fashioned by taking 2 pieces of cartilage from the superior portion of the resected quadrangular cartilage and scoring the middle area between these cartilage pieces that measure approximately 2 x 1 mm thick x 18 mm long. The left sided cartilage spreader graft is fashioned by trimming the inferior strip cartilage that is removed from the lower portion of the septum. 22. If there is a large spur to be present, this could be removed with a chisel and a mallet or possibly using a Boies elevator in the appropriate nasal vault to push the spur and residual cartilage in a medial direction. With the spur removed, we would redirect attention to insertion of cartilage into the upper cartilage wall. 23. Prior to inserting this cartilage, I would detach the inferior half of the upper lateral cartilage on the left side from the left side of the septum. 24. To insert the grafts, I place the cartilage grafts by taking 2 pieces of cartilage on the right, passing a 4-0 Monocryl suture or Y315 suture through the skin at the bony cartilaginous junction on the right after tagging the end of the suture with a hemostat. The suture will be passed out through the left hemi-transfixion incision after passing the suture through and through the septal grafts that need to be sewn together. After these grafts are sewn together, I would then pass the suture between the upper lateral cartilage and lower lateral cartilage junction on the right of the midline and I would use a stay suture of Y315 Monocryl to pull the cartilage graft into the position between the septum and the ipsilateral upper lateral cartilage. Then, I would repeat this procedure on the left side of the midline with the 4-0 Monocryl (Y315) suture after tagging the end of the suture with a hemostat. The suture would go through the spreader graft on the left fashioned from the inferior strip of cartilage and then back up to the upper cartilage and lower cartilage junction on the left of the midline. 25. After correcting the nasal valve position, the incisions are closed with multiple interrupted sutures of 5-0 Monocryl suture. 26. I pull the hemostats holding the 4-0 Monocryl sutures in the anterior direction and close the septal flaps with a mattress suture of a 4-0 Vicryl (J214) suture in a left to right and right to left alternating fashion, starting just posterior to the spreader grafts. This prevents posterior migration of the grafts along the residual septal cartilage. 27. Thereafter, I evaluate the septum and place Reuter Bivalve splints (standard thin 0.25 mm thick) on either side of the septum and secure them with a 4-0 nylon suture. 28. The external dressing of ½” Steri-Strips and Mastisol would be applied to nose. 29. The patient has an NG tube passed to the stomach to evacuate contents. 30. The patient is allowed to awaken and extubated after placing a nasal drip pad. © Michael A. Agostino, MD, FACS January 13, 2010 Modified from notes from March 1, 1998.